The news recently buzzed about the Five Star Quality Ratings published for skilled nursing facilities. I was excited myself until I looked further into how the ratings were actually calculated. The ratings are based on three categories of data: health inspections, staffing and quality measures. To read the explanation regarding determination of quality ratings visit The Medicare website 5 Star Quality Ratings explanation page.
The category entitled Health Inspections is the ONLY category that provides information derived from trained teams of surveyors. However the category descriptor also mentions that there are "many differences in state licensing requirements that affect quality, and in state Medicaid programs that pay for much of the care in nursing homes." Additionally, "inspections do not identify nursing homes that give outstanding care. While reading these reports, keep in mind that the quality of a nursing home may get much better or much worse in a short period of time. These changes can occur when a nursing home's administrator or ownership changes or when a nursing home's finances suddenly change."
This statement says more about the care provided in a nursing home than most. Staff changes have significant ramifications on the care provided in a nursing home. Often when an administrator leaves many staff members also leave, resulting in significant gaps in patient care and coordination until new staff is up and running. I have personally experienced this myself when I have had clients in certain facilities, many of whom I would have previously recommended but would now not place my worst enemy. When looking for a good nursing home for a family member multiple factors should be considered including the annual survey which can serve as a starting point.
The second category Staffing, was based on "the overall number of staff compared to the number of residents and how many of the staff are trained nurses". This number was self-reported meaning that the rating relies on the integrity of the nursing home providing the information. Research shows that relying on numbers only is not a realistic measure of quality. After all how many times have we heard the joke "how many xyz does it take to change a light bulb?"
More relevant, an article in The Gerontologist related staffing levels and nursing home quality by focusing on staff stability, stating that "highly stable employees are likely to deliver consistent care and have a greater appreciation for care practices."
Staffing quality is not only a numbers game. Many times it depends on the care provided by individuals who have been with a facility for a number of years. Time indicates commitment to care as working for any length of time in a nursing home environment not only takes commitment but love of caring for others. The difficulty of the work is one of the reasons many facilities have high turnover especially if the employees do not receive sufficient support from supervisors and the company operating the facility.
Even more interesting is the category entitled Quality Measures which reports how well each nursing home performs on ten aspects of care such as dressing eating and preventing skin ulcers. These quality measures again are self-reported by each nursing home and I suspect the degree of quality is also self interpreted. How many individuals do you know that would purposely rate themselves as sub-standard giving only one or two stars.
This is the more important reason to visit several nursing homes. Meet with the staff. Are they responsive and do they have time for your questions? Pay attention to your first impressions. Ask other family members how they feel about the care. While there is a complaint outlet, called the ombudsman, few families proceed to file complaints about care. This often leads to individuals being placed in sub-standard homes because no family member wanted to complain.
Let me play devil's advocate. Thirty three percent of the star rating is provided by a trained team of surveyors and the remaining 66% self reported. I would say that the ratings are more questionable than not especially taking into consideration that the surveys are done during a "snapshot" of time when many nursing homes are on their best behavior and the survey itself mentions quality can change at the drop of a hat.
So how does one determine what makes a good nursing home? It is not easy, especially if you're a family member trying to make a choice and are held captive by an insurance company that dictates which nursing homes are covered by your insurance. When in doubt about your ability to investigate for appropriate care, seek expert advice.
1) Castle, Nicholas G et. al. Further Examination of the Influence of Caregiver Staffing Levels on Nursing Home Quality. Vol. 48, No. 4, 464-476.
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